case study research about bullying

• Research article
• Open access
• Published: 14 December 2021

Bullying at school and mental health problems among adolescents: a repeated cross-sectional study

• Håkan Källmén 1 &
• Mats Hallgren   ORCID: orcid.org/0000-0002-0599-2403 2  

Child and Adolescent Psychiatry and Mental Health volume  15 , Article number:  74 ( 2021 ) Cite this article

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To examine recent trends in bullying and mental health problems among adolescents and the association between them.

A questionnaire measuring mental health problems, bullying at school, socio-economic status, and the school environment was distributed to all secondary school students aged 15 (school-year 9) and 18 (school-year 11) in Stockholm during 2014, 2018, and 2020 (n = 32,722). Associations between bullying and mental health problems were assessed using logistic regression analyses adjusting for relevant demographic, socio-economic, and school-related factors.

The prevalence of bullying remained stable and was highest among girls in year 9; range = 4.9% to 16.9%. Mental health problems increased; range = + 1.2% (year 9 boys) to + 4.6% (year 11 girls) and were consistently higher among girls (17.2% in year 11, 2020). In adjusted models, having been bullied was detrimentally associated with mental health (OR = 2.57 [2.24–2.96]). Reports of mental health problems were four times higher among boys who had been bullied compared to those not bullied. The corresponding figure for girls was 2.4 times higher.

Conclusions

Exposure to bullying at school was associated with higher odds of mental health problems. Boys appear to be more vulnerable to the deleterious effects of bullying than girls.

Introduction

Bullying involves repeated hurtful actions between peers where an imbalance of power exists [ 1 ]. Arseneault et al. [ 2 ] conducted a review of the mental health consequences of bullying for children and adolescents and found that bullying is associated with severe symptoms of mental health problems, including self-harm and suicidality. Bullying was shown to have detrimental effects that persist into late adolescence and contribute independently to mental health problems. Updated reviews have presented evidence indicating that bullying is causative of mental illness in many adolescents [ 3 , 4 ].

There are indications that mental health problems are increasing among adolescents in some Nordic countries. Hagquist et al. [ 5 ] examined trends in mental health among Scandinavian adolescents (n = 116, 531) aged 11–15 years between 1993 and 2014. Mental health problems were operationalized as difficulty concentrating, sleep disorders, headache, stomach pain, feeling tense, sad and/or dizzy. The study revealed increasing rates of adolescent mental health problems in all four counties (Finland, Sweden, Norway, and Denmark), with Sweden experiencing the sharpest increase among older adolescents, particularly girls. Worsening adolescent mental health has also been reported in the United Kingdom. A study of 28,100 school-aged adolescents in England found that two out of five young people scored above thresholds for emotional problems, conduct problems or hyperactivity [ 6 ]. Female gender, deprivation, high needs status (educational/social), ethnic background, and older age were all associated with higher odds of experiencing mental health difficulties.

Bullying is shown to increase the risk of poor mental health and may partly explain these detrimental changes. Le et al. [ 7 ] reported an inverse association between bullying and mental health among 11–16-year-olds in Vietnam. They also found that poor mental health can make some children and adolescents more vulnerable to bullying at school. Bayer et al. [ 8 ] examined links between bullying at school and mental health among 8–9-year-old children in Australia. Those who experienced bullying more than once a week had poorer mental health than children who experienced bullying less frequently. Friendships moderated this association, such that children with more friends experienced fewer mental health problems (protective effect). Hysing et al. [ 9 ] investigated the association between experiences of bullying (as a victim or perpetrator) and mental health, sleep disorders, and school performance among 16–19 year olds from Norway (n = 10,200). Participants were categorized as victims, bullies, or bully-victims (that is, victims who also bullied others). All three categories were associated with worse mental health, school performance, and sleeping difficulties. Those who had been bullied also reported more emotional problems, while those who bullied others reported more conduct disorders [ 9 ].

As most adolescents spend a considerable amount of time at school, the school environment has been a major focus of mental health research [ 10 , 11 ]. In a recent review, Saminathen et al. [ 12 ] concluded that school is a potential protective factor against mental health problems, as it provides a socially supportive context and prepares students for higher education and employment. However, it may also be the primary setting for protracted bullying and stress [ 13 ]. Another factor associated with adolescent mental health is parental socio-economic status (SES) [ 14 ]. A systematic review indicated that lower parental SES is associated with poorer adolescent mental health [ 15 ]. However, no previous studies have examined whether SES modifies or attenuates the association between bullying and mental health. Similarly, it remains unclear whether school related factors, such as school grades and the school environment, influence the relationship between bullying and mental health. This information could help to identify those adolescents most at risk of harm from bullying.

To address these issues, we investigated the prevalence of bullying at school and mental health problems among Swedish adolescents aged 15–18 years between 2014 and 2020 using a population-based school survey. We also examined associations between bullying at school and mental health problems adjusting for relevant demographic, socioeconomic, and school-related factors. We hypothesized that: (1) bullying and adolescent mental health problems have increased over time; (2) There is an association between bullying victimization and mental health, so that mental health problems are more prevalent among those who have been victims of bullying; and (3) that school-related factors would attenuate the association between bullying and mental health.

Participants

The Stockholm school survey is completed every other year by students in lower secondary school (year 9—compulsory) and upper secondary school (year 11). The survey is mandatory for public schools, but voluntary for private schools. The purpose of the survey is to help inform decision making by local authorities that will ultimately improve students’ wellbeing. The questions relate to life circumstances, including SES, schoolwork, bullying, drug use, health, and crime. Non-completers are those who were absent from school when the survey was completed (< 5%). Response rates vary from year to year but are typically around 75%. For the current study data were available for 2014, 2018 and 2020. In 2014; 5235 boys and 5761 girls responded, in 2018; 5017 boys and 5211 girls responded, and in 2020; 5633 boys and 5865 girls responded (total n = 32,722). Data for the exposure variable, bullied at school, were missing for 4159 students, leaving 28,563 participants in the crude model. The fully adjusted model (described below) included 15,985 participants. The mean age in grade 9 was 15.3 years (SD = 0.51) and in grade 11, 17.3 years (SD = 0.61). As the data are completely anonymous, the study was exempt from ethical approval according to an earlier decision from the Ethical Review Board in Stockholm (2010-241 31-5). Details of the survey are available via a website [ 16 ], and are described in a previous paper [ 17 ].

Students completed the questionnaire during a school lesson, placed it in a sealed envelope and handed it to their teacher. Student were permitted the entire lesson (about 40 min) to complete the questionnaire and were informed that participation was voluntary (and that they were free to cancel their participation at any time without consequences). Students were also informed that the Origo Group was responsible for collection of the data on behalf of the City of Stockholm.

Study outcome

Mental health problems were assessed by using a modified version of the Psychosomatic Problem Scale [ 18 ] shown to be appropriate for children and adolescents and invariant across gender and years. The scale was later modified [ 19 ]. In the modified version, items about difficulty concentrating and feeling giddy were deleted and an item about ‘life being great to live’ was added. Seven different symptoms or problems, such as headaches, depression, feeling fear, stomach problems, difficulty sleeping, believing it’s great to live (coded negatively as seldom or rarely) and poor appetite were used. Students who responded (on a 5-point scale) that any of these problems typically occurs ‘at least once a week’ were considered as having indicators of a mental health problem. Cronbach alpha was 0.69 across the whole sample. Adding these problem areas, a total index was created from 0 to 7 mental health symptoms. Those who scored between 0 and 4 points on the total symptoms index were considered to have a low indication of mental health problems (coded as 0); those who scored between 5 and 7 symptoms were considered as likely having mental health problems (coded as 1).

Primary exposure

Experiences of bullying were measured by the following two questions: Have you felt bullied or harassed during the past school year? Have you been involved in bullying or harassing other students during this school year? Alternatives for the first question were: yes or no with several options describing how the bullying had taken place (if yes). Alternatives indicating emotional bullying were feelings of being mocked, ridiculed, socially excluded, or teased. Alternatives indicating physical bullying were being beaten, kicked, forced to do something against their will, robbed, or locked away somewhere. The response alternatives for the second question gave an estimation of how often the respondent had participated in bullying others (from once to several times a week). Combining the answers to these two questions, five different categories of bullying were identified: (1) never been bullied and never bully others; (2) victims of emotional (verbal) bullying who have never bullied others; (3) victims of physical bullying who have never bullied others; (4) victims of bullying who have also bullied others; and (5) perpetrators of bullying, but not victims. As the number of positive cases in the last three categories was low (range = 3–15 cases) bully categories 2–4 were combined into one primary exposure variable: ‘bullied at school’.

Assessment year was operationalized as the year when data was collected: 2014, 2018, and 2020. Age was operationalized as school grade 9 (15–16 years) or 11 (17–18 years). Gender was self-reported (boy or girl). The school situation To assess experiences of the school situation, students responded to 18 statements about well-being in school, participation in important school matters, perceptions of their teachers, and teaching quality. Responses were given on a four-point Likert scale ranging from ‘do not agree at all’ to ‘fully agree’. To reduce the 18-items down to their essential factors, we performed a principal axis factor analysis. Results showed that the 18 statements formed five factors which, according to the Kaiser criterion (eigen values > 1) explained 56% of the covariance in the student’s experience of the school situation. The five factors identified were: (1) Participation in school; (2) Interesting and meaningful work; (3) Feeling well at school; (4) Structured school lessons; and (5) Praise for achievements. For each factor, an index was created that was dichotomised (poor versus good circumstance) using the median-split and dummy coded with ‘good circumstance’ as reference. A description of the items included in each factor is available as Additional file 1 . Socio-economic status (SES) was assessed with three questions about the education level of the student’s mother and father (dichotomized as university degree versus not), and the amount of spending money the student typically received for entertainment each month (> SEK 1000 [approximately $120] versus less). Higher parental education and more spending money were used as reference categories. School grades in Swedish, English, and mathematics were measured separately on a 7-point scale and dichotomized as high (grades A, B, and C) versus low (grades D, E, and F). High school grades were used as the reference category.

Statistical analyses

The prevalence of mental health problems and bullying at school are presented using descriptive statistics, stratified by survey year (2014, 2018, 2020), gender, and school year (9 versus 11). As noted, we reduced the 18-item questionnaire assessing school function down to five essential factors by conducting a principal axis factor analysis (see Additional file 1 ). We then calculated the association between bullying at school (defined above) and mental health problems using multivariable logistic regression. Results are presented as odds ratios (OR) with 95% confidence intervals (Cis). To assess the contribution of SES and school-related factors to this association, three models are presented: Crude, Model 1 adjusted for demographic factors: age, gender, and assessment year; Model 2 adjusted for Model 1 plus SES (parental education and student spending money), and Model 3 adjusted for Model 2 plus school-related factors (school grades and the five factors identified in the principal factor analysis). These covariates were entered into the regression models in three blocks, where the final model represents the fully adjusted analyses. In all models, the category ‘not bullied at school’ was used as the reference. Pseudo R-square was calculated to estimate what proportion of the variance in mental health problems was explained by each model. Unlike the R-square statistic derived from linear regression, the Pseudo R-square statistic derived from logistic regression gives an indicator of the explained variance, as opposed to an exact estimate, and is considered informative in identifying the relative contribution of each model to the outcome [ 20 ]. All analyses were performed using SPSS v. 26.0.

Prevalence of bullying at school and mental health problems

Estimates of the prevalence of bullying at school and mental health problems across the 12 strata of data (3 years × 2 school grades × 2 genders) are shown in Table 1 . The prevalence of bullying at school increased minimally (< 1%) between 2014 and 2020, except among girls in grade 11 (2.5% increase). Mental health problems increased between 2014 and 2020 (range = 1.2% [boys in year 11] to 4.6% [girls in year 11]); were three to four times more prevalent among girls (range = 11.6% to 17.2%) compared to boys (range = 2.6% to 4.9%); and were more prevalent among older adolescents compared to younger adolescents (range = 1% to 3.1% higher). Pooling all data, reports of mental health problems were four times more prevalent among boys who had been victims of bullying compared to those who reported no experiences with bullying. The corresponding figure for girls was two and a half times as prevalent.

Associations between bullying at school and mental health problems

Table 2 shows the association between bullying at school and mental health problems after adjustment for relevant covariates. Demographic factors, including female gender (OR = 3.87; CI 3.48–4.29), older age (OR = 1.38, CI 1.26–1.50), and more recent assessment year (OR = 1.18, CI 1.13–1.25) were associated with higher odds of mental health problems. In Model 2, none of the included SES variables (parental education and student spending money) were associated with mental health problems. In Model 3 (fully adjusted), the following school-related factors were associated with higher odds of mental health problems: lower grades in Swedish (OR = 1.42, CI 1.22–1.67); uninteresting or meaningless schoolwork (OR = 2.44, CI 2.13–2.78); feeling unwell at school (OR = 1.64, CI 1.34–1.85); unstructured school lessons (OR = 1.31, CI = 1.16–1.47); and no praise for achievements (OR = 1.19, CI 1.06–1.34). After adjustment for all covariates, being bullied at school remained associated with higher odds of mental health problems (OR = 2.57; CI 2.24–2.96). Demographic and school-related factors explained 12% and 6% of the variance in mental health problems, respectively (Pseudo R-Square). The inclusion of socioeconomic factors did not alter the variance explained.

Our findings indicate that mental health problems increased among Swedish adolescents between 2014 and 2020, while the prevalence of bullying at school remained stable (< 1% increase), except among girls in year 11, where the prevalence increased by 2.5%. As previously reported [ 5 , 6 ], mental health problems were more common among girls and older adolescents. These findings align with previous studies showing that adolescents who are bullied at school are more likely to experience mental health problems compared to those who are not bullied [ 3 , 4 , 9 ]. This detrimental relationship was observed after adjustment for school-related factors shown to be associated with adolescent mental health [ 10 ].

A novel finding was that boys who had been bullied at school reported a four-times higher prevalence of mental health problems compared to non-bullied boys. The corresponding figure for girls was 2.5 times higher for those who were bullied compared to non-bullied girls, which could indicate that boys are more vulnerable to the deleterious effects of bullying than girls. Alternatively, it may indicate that boys are (on average) bullied more frequently or more intensely than girls, leading to worse mental health. Social support could also play a role; adolescent girls often have stronger social networks than boys and could be more inclined to voice concerns about bullying to significant others, who in turn may offer supports which are protective [ 21 ]. Related studies partly confirm this speculative explanation. An Estonian study involving 2048 children and adolescents aged 10–16 years found that, compared to girls, boys who had been bullied were more likely to report severe distress, measured by poor mental health and feelings of hopelessness [ 22 ].

Other studies suggest that heritable traits, such as the tendency to internalize problems and having low self-esteem are associated with being a bully-victim [ 23 ]. Genetics are understood to explain a large proportion of bullying-related behaviors among adolescents. A study from the Netherlands involving 8215 primary school children found that genetics explained approximately 65% of the risk of being a bully-victim [ 24 ]. This proportion was similar for boys and girls. Higher than average body mass index (BMI) is another recognized risk factor [ 25 ]. A recent Australian trial involving 13 schools and 1087 students (mean age = 13 years) targeted adolescents with high-risk personality traits (hopelessness, anxiety sensitivity, impulsivity, sensation seeking) to reduce bullying at school; both as victims and perpetrators [ 26 ]. There was no significant intervention effect for bullying victimization or perpetration in the total sample. In a secondary analysis, compared to the control schools, intervention school students showed greater reductions in victimization, suicidal ideation, and emotional symptoms. These findings potentially support targeting high-risk personality traits in bullying prevention [ 26 ].

The relative stability of bullying at school between 2014 and 2020 suggests that other factors may better explain the increase in mental health problems seen here. Many factors could be contributing to these changes, including the increasingly competitive labour market, higher demands for education, and the rapid expansion of social media [ 19 , 27 , 28 ]. A recent Swedish study involving 29,199 students aged between 11 and 16 years found that the effects of school stress on psychosomatic symptoms have become stronger over time (1993–2017) and have increased more among girls than among boys [ 10 ]. Research is needed examining possible gender differences in perceived school stress and how these differences moderate associations between bullying and mental health.

Strengths and limitations

Strengths of the current study include the large participant sample from diverse schools; public and private, theoretical and practical orientations. The survey included items measuring diverse aspects of the school environment; factors previously linked to adolescent mental health but rarely included as covariates in studies of bullying and mental health. Some limitations are also acknowledged. These data are cross-sectional which means that the direction of the associations cannot be determined. Moreover, all the variables measured were self-reported. Previous studies indicate that students tend to under-report bullying and mental health problems [ 29 ]; thus, our results may underestimate the prevalence of these behaviors.

In conclusion, consistent with our stated hypotheses, we observed an increase in self-reported mental health problems among Swedish adolescents, and a detrimental association between bullying at school and mental health problems. Although bullying at school does not appear to be the primary explanation for these changes, bullying was detrimentally associated with mental health after adjustment for relevant demographic, socio-economic, and school-related factors, confirming our third hypothesis. The finding that boys are potentially more vulnerable than girls to the deleterious effects of bullying should be replicated in future studies, and the mechanisms investigated. Future studies should examine the longitudinal association between bullying and mental health, including which factors mediate/moderate this relationship. Epigenetic studies are also required to better understand the complex interaction between environmental and biological risk factors for adolescent mental health [ 24 ].

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Acknowledgements

Authors are grateful to the Department for Social Affairs, Stockholm, for permission to use data from the Stockholm School Survey.

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HK conceived the study and analyzed the data (with input from MH). HK and MH interpreted the data and jointly wrote the manuscript. All authors read and approved the final manuscript.

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Principal factor analysis description.

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Källmén, H., Hallgren, M. Bullying at school and mental health problems among adolescents: a repeated cross-sectional study. Child Adolesc Psychiatry Ment Health 15 , 74 (2021). https://doi.org/10.1186/s13034-021-00425-y

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A Systematic Review of Bullying and Victimization Among Adolescents in India

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• Published: 07 September 2020
• Volume 3 , pages 253–269, ( 2021 )

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• Niharika Thakkar   ORCID: orcid.org/0000-0001-8754-6708 1 ,
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This study provides a systematic review of literature from India on traditional bullying and victimization among school-going adolescents. A search of bibliographic electronic databases PsycINFO, MEDLINE, ERIC, Web of Science, and PubMed was performed in May 2020. Thirty-seven studies were included in the review. For each study included, the following specifics were examined: (a) methodological characteristics, (b) prevalence estimates of bullying behavior, (c) forms of bullying, (d) risk factors, and (e) consequences of bullying. It was found that bullying happens in India, and some risk factors for bullying and victimization in India are typical to the Indian context. In addition, bullying in India is associated with adverse consequences for both the aggressor and the victim. Many studies on bullying from India should be interpreted cautiously because of problems with data collection processes, instrumentation, and presentation of the findings. Cross-cultural comparisons for prevalence estimates, and longitudinal studies to examine the direction of possible influence between bullying and its correlates need to be conducted, to cater to the large adolescent population of India.

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Prevalence and factors associated with bullying phenomenon among pre-adolescents attending first-grade secondary schools of Palermo, Italy, and a comparative systematic literature review

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Bullying is an intentional and repetitive act of physical or psychological aggression, where the aggressor is more powerful than the victim (Olweus 1993 ). Meta-analytic studies have confirmed the marked prevalence of and risk factors associated with bullying perpetration and victimization among children and adolescents in school (Modecki et al. 2014 ). In a recent survey conducted in 79 countries with over 300,000 participants, 30% of the adolescent respondents reported that they had been victims of bullying in the past 30 days (Elgar et al. 2015 ). In India, research on bullying is scarce, certainly in proportion to its population size, as well as socio-cultural diversity (Milfont and Fischer 2010 ; Smith et al. 2018 ). The vast adolescent population provides ample opportunity and resources to further our understanding in the field of bullying. The disparities seen in India in terms of socio-cultural factors such as SES, religion, caste, gender, and color, which have been recognized as typical to the Indian context (Panda and Gupta 2004 ), may aid in breeding an imbalance of power, an underlying element of bullying (Olweus 1993 ). Moreover, given the diverse socio-cultural context of India, and its structural incongruence with western cultures (Charak and Koot 2015 ), literature from western countries may not be generalizable to the Indian population, thus requiring scientific attention to examine the role of these factors specifically in India (Smith et al. 2018 ).

Through the current review, we aim to provide researchers a notion of challenges that need to be addressed in future studies on bullying and victimization in India. Systematic reviews are of importance, because they closely follow a scientific and step-by-step approach, with an aim of limiting systematic errors or bias, and particularly seek to identify, evaluate, and synthesize all relevant studies to elucidate knowledge and advanced understanding of the topic at hand (Petticrew and Roberts 2008 ). The present systematic review focuses on traditional bullying and victimization among adolescents in schools in India, highlighting the following specifics: (a) methodological characteristics of included studies, (b) prevalence estimates of bullying behavior, (c) forms of bullying, (d) risk factors, and (e) consequences of bullying. Specifically, we examine the psychometric properties of the instruments adopted in the included studies from India, as well as methodological characteristics including design and data collection, sample size and sampling procedures of the included studies, and characteristics of bullying behavior distinctive to the Indian context.

Guidelines provided by Arksey and O’Malley ( 2005 ) for conducting systematic reviews were followed in the present study. A systematic search of bibliographic electronic databases PsycINFO, MEDLINE, ERIC, Web of Science, and PubMed was performed in May 2020. The following terms formed the basis of the search strategy: “bullying” OR “peer victim*” OR “bullied” OR “bully” OR “school harassment*” OR “ragging” OR “school violence*” AND “India” OR “Indian” OR “Hindi”. No date limit was set for the search. Our search was not limited to published articles; book chapters, dissertations, unpublished articles, and posters were also eligible. A flow diagram of the search results is provided in Fig. 1 . Only studies that focused on bullying by peers and the resulting victimization at school were included. Articles on online bullying or cyberbullying were excluded. There were too few studies on cyberbullying in India to provide a meaningful analysis, especially when such an analysis should also deal with recent concerns about cyberbullying studies (e.g., Wolke et al. 2017 ). Non-empirical studies that did not include quantifiable data (for instance, book reviews) were excluded as we focus on only empirical research in the current review. Six studies used interviews to gather data; for instance, Kshirsagar et al. ( 2007 ) used Olweus’s ( 1996 ) pre-tested semi-structure interview to collect data on bullying and victimization in their study. The answers to these interviews were quantified and used in statistical analyses, and therefore, we included the articles in the current review. Studies on Indian children who live outside of India were excluded. Because we focused on adolescents in school, the age of students in included studies should range between 10 and 19 years. For studies on students whose ages only partly overlapped with this intended range, we applied the rule that the average age should fall within the intended range and the lowest and highest age should be within 2 years of the intended age limits. Two studies did not provide a definitive age range of the participants included in their study (Patel et al. 2017 ; Schäfer et al. 2018 ); however, the studies indicate that the participants were from grade 8 to 10 (who are typically 12 to 15 years old), thereby qualifying for inclusion in the present review. Three studies did not provide the mean age of the participants in their study though they specify the age range of the participants (Kshirsagar et al. 2007 ; Malik and Mehta 2016 ; Ramya and Kulkarni 2011 ), and because the lower limit or higher limit of the provided age range in these three study fell within 2 years of 11–19 years old, we have included them in the present review. Eventually, 37 studies were included in the final review.

Search results for the systematic review

Methodological Characteristics of Included Studies

Design and data collection.

Of the 37 studies that were included, two were longitudinal studies (Nguyen et al. 2017 ; Thakkar et al. 2020 ), two were experimental studies with pre- and post-test intervention designs (Sharma et al. 2020 ; Shinde et al. 2018 , 2020 ), whereas the others were cross-sectional studies. Seven of the 37 studies used peer-reports, 21 studies used self-reports, two studies used both self- and peer-reports (Chakrabartty and Gupta 2016 ; Thakkar et al. 2020 ), whereas six studies used structured or semi-structured interviews and open-ended questions to collect data on bullying and victimization (Kshirsagar et al. 2007 ; Malhi et al. 2014 , 2015 ; Malik and Mehta 2016 ; Munni and Malhi 2006 ; Ramya and Kulkarni 2011 ). One study used a photo-story method (Skrzypiec et al. 2015 ), where participants were invited to use a photograph or picture to illustrate their opinions or experiences of bullying.

Psychometric Properties

Psychometric properties of the scales or interviewing approaches used in the studies have been reported in 22 of the 37 studies. Four studies reported the reliability and validity of the original scale (Malik and Mehta 2016 ; Menon and Hannah-Fisher 2019 ; Patel et al. 2017 ; Samanta et al. 2012 ), but did not report psychometric properties based on the Indian sample, while five studies reported neither the psychometric properties of the original scale nor its generalizability to the Indian sample (Kshirsagar et al. 2007 ; Maji et al. 2016 ; Sarkhel et al. 2006 ; Sharma et al. 2017 ; Sethi et al. 2019 ). Two studies used a scale developed by the authors of the study; however, psychometric properties were not reported (Kelly et al. 2016 ; Prakash et al. 2017 ). Four studies did not provide a clear description of the method of data collection, and the validity of the approach was not defined (Malhi et al. 2014 , 2015 ; Munni and Malhi 2006 ; Ramya and Kulkarni 2011 ). Seven studies specified that the instrument used to assess bullying behavior was an English language questionnaire, while 10 studies used either existing translations or translations created by the authors of the study, of English scales into Indian regional languages. Two studies used English instruments and orally explained the translation in Punjabi (Lee et al. 2018 ) or translated the difficult words to Hindi (Malik and Mehta 2016 ), and one study used English and Hindi language translations of the scales (Thakkar et al. 2020 ).

Of the 37 studies, 25 studies used a convenience or purposive sampling approach to recruit participants. One study used a proportionate random sampling approach to recruit participants (Kelly et al. 2016 ); one study used a two-stage cluster sampling approach (Swain et al. 2014 ); one used a multi-stage sampling design (Chakrabartty and Gupta 2016 ); six studies reported using a random sampling method for selecting either schools or participants (Kshirsagar et al. 2007 ; Maji et al. 2016 ; Malik and Mehta 2016 ; Nguyen et al. 2017 ; Ramya and Kulkarni 2011 ; Sarkhel et al. 2006 ), but only one of them reported how the school sample was randomized (by draw of lots; Sethi et al. 2019 ). Two studies used a randomized control design to allocate participants to experimental or control groups, where Prakash et al. ( 2017 ) used a cluster randomized control design, and the intervention study by Shinde et al. ( 2018 ) used randomized and masked groups for each of three study groups. One study used a quasi-experimental design, where of the two participating schools, one was randomly assigned to the intervention group, and the other was assigned to the control group (Sharma et al. 2020 ). Of the 37 studies included in the review, 17 studies had a sample size of less than 300 participants, nine studies had a sample size of between 300 and 500 participants, whereas 11 studies had a sample size larger than 500 participants.

The articles widely differed in their statistical reporting practices, and therefore, the amount of statistical information provided in the below sections and Table 1 varies per reported study. Time frames of bullying and victimization prevalence estimates are reported in the below sections if they were specified in the included studies. Percentages are rounded off without decimals.

Prevalence Studies

Eight studies focused on the prevalence of bullying in India, while 14 others provided descriptive statistics or percentages for sample participants that qualified as bullies or victims in their study. Of these, five studies provided the participants with a definition of bullying for peer nomination estimates of bullying and victimization in their research (Goossens et al. 2018 ; Khatri 1996 ; Lee et al. 2018 ; Skrzypiec et al. 2018a ; Thakkar et al. 2020 ). Studies from the same city or region in India were scarce, and reports inconsistent. We found that bullying perpetration estimates ranged from 7% (Thakkar et al. 2020 ) to 31% (Kshirsagar et al. 2007 ), and bullying victimization ranged from 9% (Thakkar et al. 2020 ) to 80% (Maji et al. 2016 ), across studies. For instance, Maji et al. ( 2016 ) found that only 38 of 273 adolescents were not bullied, resulting in a dominant 80% students qualifying as victims of bullying. Next to region differences in prevalence, estimates may be related to the reporter used. Kshirsagar et al. ( 2007 ) found higher prevalence rates for bullying for self-reports than for parent or guardian interviews, whereas Thakkar et al. ( 2020 ) found higher prevalence estimates for bullying and victimization for peer reports than for self-reports. Findings as regards prevalence and other findings or aspects reviewed of each study are reported in Table 1 .

Forms of Bullying

It was observed that name-calling or using bad words were common forms of bullying observed among adolescents next to physical bullying. For instance, Kshirsagar et al. ( 2007 ) reported that the most common types of bullying were teasing and giving discriminatory or offensive labels and nick names to others. Similarly, Malhi et al. ( 2014 ) reported that 16% of their sample were victims of direct bullying or physical bullying and 34% were victims of name-calling. Skrzypiec et al. ( 2015 ) showed that caste-based bullying was reported by students and that for females, sexual harassment or “eve-teasing” was a common occurrence.

Risk Factors for Bullying and Victimization

Thirteen studies from India focus on the risk factors and correlates of bullying and victimization. Risk factors refer to variables that have the potential to increase or decrease the likelihood of bullying behaviors occurring (Olweus 1996 ), whereas correlates of bullying behaviors focus on factors that are significantly associated with, and co-occur with, bullying behaviors. Risk factors for bullying and victimization identified through the review were body weight (Patel et al. 2017 ), religion (Thakkar et al. 2020 ), and age (Malhi et al. 2015 ; Ramya and Kulkarni 2011 ), and factors that were found to be significantly correlated to bullying behaviors were personality traits (neuroticism; Donat et al. 2012 ), academic performance (Patel et al. 2017 ), urban/rural setting (Nguyen et al. 2017 ; Samanta et al. 2012 ), and father’s education level (Sethi et al. 2019 ). Factors that were found to be risks or correlates of bullying behavior in various studies included in the review were caste-system of India (Kelly et al. 2016 ; Sethi et al. 2019 ; Thakkar et al. 2020 ), socio-economic status (Malhi et al. 2015 ; Sethi et al. 2019 ), and gender differences.

Studies focusing on the caste system of India reported contradictory findings ranging from “General” caste students experiencing lower harassment (Kelly et al. 2016 ), “General” caste students experiencing more victimization (Thakkar et al. 2020 ), to no differences between castes (Khatri  1996 ). As regards the role of religion, Thakkar et al. ( 2020 ) reported that non-Hindu children were significantly more likely to classify as victims than Hindu children. For SES, Malhi et al. ( 2015 ) found a significant relationship between SES and victimization, with low SES students scoring higher on physical victimization, whereas high SES students scored higher on relational victimization. For gender comparison, although not fully consistent, most studies within India reported that boys scored higher than girls on bullying perpetration and bullying victimization (Narayanan and Betts 2014 ; Nguyen et al. 2017 ; Patel et al. 2017 ; Pronk et al. 2017 ; Ramya and Kulkarni 2011 ; Sethi et al. 2019 ; Sharma et al. 2017 ; Swain et al. 2014 ). Age was also found to have some, though inconsistent, relationship with bullying behavior in school (Malhi et al. 2015 ; Patel et al. 2017 ; Ramya and Kulkarni 2011 ).

Consequences of Bullying

Being bullied was found to be associated with anxiety, depression, and preferring to stay alone (Kshirsagar et al. 2007 ). Also, bullied children were more likely to report symptoms such as school phobia, vomiting, catastrophizing, self-blaming, and sleep disturbances (Kshirsagar et al. 2007 ; Maji et al. 2016 ). Bully-victims had higher risk of conduct problems, hyperactivity, and academic difficulties, and while bullies were found to be better at academics, they had high self-esteem, and higher risk of hyperactivity and conduct problems (Malhi et al. 2014 ; Sarkhel et al. 2006 ).

Based on the syntheses of studies included in our review, we draw the following conclusions: (a) limitations in methodological characteristics of studies were identified with regard to sampling, instrumentation, data collection processes, and presentation of findings, and thus, conclusions from the included studies must be considered cautiously; (b) bullying happens in India, as it does internationally, though the range of prevalence estimates varies widely across studies; (c) name-calling, using bad words and other forms of relational and social bullying are common in India, and physical bullying is also prevalent; (d) risk factors for bullying and victimization in India show some factors that are typical to the Indian context, for example, caste; and (e) bullying is associated with adverse consequences for both, the aggressor and the victim, in India.

The current review notes that bullying is widely spread in India. However, available prevalence estimates vary largely across India, for bullying perpetration and for victimization. India is a geographically vast country, with enormous differences in regional socio-demographics (Charak and Koot 2015 ), thereby constraining prevalence estimates to stratified regions. Scholars have noted that homogeneity within culture in India, like in many other countries, cannot be assumed (Panda and Gupta 2004 ). Thus, generalizing regional prevalence estimates to be representative across India is questionable, calling attention to the need to conduct cross-regional and cross-cultural comparative studies of bullying behavior within the country.

Furthermore, the type of instruments and their psychometric properties impact the findings of a study (Milfont and Fischer 2010 ), thereby not only making prevalence estimates from studies in the present review questionable but also warranting caution to conclusions. Also, conclusions about similarities or differences between the Indian and Western contexts require that metric invariance first be established to allow cross-ethnic and cross-cultural comparisons (Milfont and Fischer 2010 ). Of the 37 studies included in the present review, 22 studies provided descriptions of the psychometric properties of the instruments used, while 15 studies did not report the properties of instruments in their study raising concerns about comparability across studies in terms of instruments used. Furthermore, most studies on bullying in India adopted a quantitative method of data collection, where only 6 out of the included 37 in the present review used a qualitative approach to collect data for their research. The concerns about validity are increased by the over reliance on self-reports; we found that only 7 of the 37 studies used peer-reports, and 2 studies used self- as well as informant reports. In self-rating procedures, pupils tend to underestimate their aggressive behavior and emphasize prosocial behavior on account of social desirability (Salmivalli et al. 1996 ). There is an urgent need to validate and standardize instruments, with special attention to peer reports that assess bullying behaviors and establish their generalizability to Indian samples, to attain unbiased reports of bullying behavior in India (Sousa and Rojjanasrirat 2011 ).

Furthermore, only few studies included a sample that is sizable enough to provide firm, stable conclusions (Naing et al. 2006 ), and thus, the basis for the generalizability of the reports on the prevalence is very narrow. Ioannidis ( 2005 ) asserted that the smaller the sample sizes in a study, the smaller the power of the study, and consequently the higher the likelihood of the research findings to be affected by bias. Thus, we emphasize the need to conduct more studies across India, with proportional sample sizes for objective, less biased conclusions regarding bullying behavior. Also, the purposive selection of participants in 25 of the 37 included studies poses a potential threat to the validity of findings. In future studies, random sampling approaches should be used to study bullying in India.

Furthermore, we observe that there are only two longitudinal studies from India (Nguyen et al. 2019 ; Thakkar et al. 2020 ). Longitudinal studies help disentangle antecedents and consequents, to estimate the inter-individual variability in intra-individual (or within-person) patterns of change (Curran et al. 2010 ), allowing investigations of the sequence of occurrence of bullying with its risks and outcomes. Additionally, several studies in the present review report the adverse effects of bullying; however, the magnitude of these effects remains unclear. Only two of the 37 included studies were experimental studies with pre- and post-test intervention designs (Sharma et al. 2020 ; Shinde et al. 2018 , 2020 ), which also underlines the urgent need to conduct fundamental indigenous research on the topic of bullying behaviors so that future research focusing on effective and tailor-cut interventions can be modeled for the Indian context. Also, given that most studies included were cross-sectional, cause and effect reasoning for bullying behavior remains elusive in India, and warrants further attention.

Lastly, we emphasize that risk factors of bullying need to be studied in light of the Indian culture to understand its meaning and relevance in the culture (Smith et al. 2018 ). In western literature as well, several recent studies have indicated a growing need to study bullying in relation to its broader socio-cultural context (Graham 2016 ). This is imperative in the Indian context given the contextual-development perspective (Chen and French 2008 ), which suggests that in collectivistic countries like India, context is more likely to affect evaluations of socially acceptable behavior and experiences, rather than individual attributes. Given the diversity and population density of India, considerable disparities and inequalities co-exist between cultures and also within the sub-groups of particular cultures (Panda and Gupta 2004 ). For instance, factors such as caste, dissimilarities between urban and rural youth, and the range of SES as observed in India can help in better, more deeply understanding bullying.

Conclusions and Implications for Future Research

This review contributes valuable findings in the field of bullying and victimization in India. However, it has been noted that conducting research in India comes with its own set of logistical and contextual challenges (Smith et al. 2018 ), and thus, the conclusions drawn through the review must be considered with due caution given methodological limitations of the included studies. The quality of research conducted in India has scope of improvement in terms of methodological rigor, data collection processes, instrumentation, and presentation of the findings.

The present study is limited in capacity as it does not include a report on cyberbullying, and thus, future research on the topic of cyberbullying is necessitated within the Indian context. Furthermore, terms such as “aggression” and “discrimination” were not used as search terms in the current study. However, bullying is a form of aggression, and discrimination could be, in some cases, strongly tied to bullying (Verkuyten and Thijs 2002 ). Future studies should pay more attention to the relations between bullying and discrimination.

In contrast to the large body of research on bullying from western countries where findings have been reproduced with a delimited adolescent population insistently, data from India is scanty. India accommodates the largest adolescent population in the world, providing a potential reservoir of relatively untapped resources that could provide in-depth knowledge of causes and consequences of bullying and victimization. Given its special cultural context, there is considerable scope to scrutinize cultural contexts of bullying behavior in India that could assist in revealing novel insights, such as the role of socio-economic distance between different sects of society in low to middle income countries. Such insights might facilitate the conception of dynamic intervention designs for not only the Indian population but also for western populations. Future studies that compare how bullying happens in the western and Indian context would also help shed further light on this topic.

Study 3 (Correia et al. 2009 ) and 4 (Donat et al. 2012 ) have the same Indian sample in their studies. However, the variables examining correlates and consequences of bullying are different in the studies, and thus for the purpose of our review, we include both studies.

Study 8 by Khatri and Kupersmidt ( 2003 ) is based on a dissertation thesis submitted to University of North Carolina by the first author in 1996. For the purpose of our review, we consider the dissertation and the journal article as one inclusion since the participants as well as bullying reports are the same for both.

Study 19 (Nguyen et al. 2017 ) and 20 (Nguyen et al. 2019 ) have the same Indian sample in their studies. However, the former paper focuses on prevalence and forms of bullying and victimization, whereas the latter one examines psychosocial outcomes of victimization, and thus, we include both studies separately in the present review.

Study 32 includes reports from two articles (Shinde et al. 2018 ; Shinde et al. 2020 ). The studies use an intervention design with the same sample, and include reports after 12-month follow-up and 17-month follow-up of the design, both of which have been reported in point 32 in the present review.

Study 35 (Suresh and Tipandjan 2012 ) uses a retrospective bullying questionnaire with undergraduate college students. As the study focuses on bullying behavior in school retrospectively with adolescents, we included the study in the present review.

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Thakkar, N., van Geel, M. & Vedder, P. A Systematic Review of Bullying and Victimization Among Adolescents in India. Int Journal of Bullying Prevention 3 , 253–269 (2021). https://doi.org/10.1007/s42380-020-00081-4

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Bullying: A Case Study Revisited

Cruelty and its impact, years later.

Posted April 9, 2015

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Several years ago, a teacher shared a scenario that exemplified how crafty and insidious bullying can be. I blogged about it at the time and reprinted the story here—as well as a followed up with the young victim:

From the outside, the abuse looked innocuous enough—kids around a table in the cafeteria, singing fragments of popular songs and laughing . Nothing to catch the attention of monitors—until another student bade a young teacher to listen carefully to the lyrics. Muse’s popular song was only tweaked, becoming "Far away / you can’t be far enough away / far away from the people who don’t care if you live or die." Instead of Lady Gaga’s lyrics, the kids chanted “you are so ugly / you are a disease. The boys don’t even want what you’re givin’ for free. No one wants your Love / Ew, yuck, ew / you’re such a joke.” Instead of Beyonce’s, “If you like it then you should’ve put a ring on it,” they sang “you’re a f*#% up and loser put a bag on it.” The repertoire was extensive, and new songs were added every week.

By and large, the students were careful to write lyrics that would pass censorship and not attract attention to themselves for profanity. They delighted in their own cleverness, and in their ability to get many uninvolved bystanders to sing a chorus as they waited in the food line. In other words, the humiliation of one girl became a popular bonding experience, and ad-libbing new lyrics was a way to get positive peer attention.

As they saw it, it was all just a joke. Ha Ha. Can’t she take a little joke?

Recently, I tracked down the victim (she is at a top-tier college) and she agreed to reflect on her experiences. I first asked whether she remembered the correct lyrics to those songs, all these years later. My mistake. I assumed the alternate lyrics were seared into her brain. Instead, she told me she had forgotten the revised songs, and would not have recalled the lyrics had I not transcribed them, years ago. When I asked whether she had ever gotten an apology , or if one would change anything now, she didn’t think there was any need.

Gratifying as it was to see her doing well, these were not the responses I anticipated. But as parents and educators think about bullying, it is important to keep in mind that not all incidents—not even all ongoing cruelties that clearly affect a young adult—will scar her for life. And that we may, at times, do a disservice to young people by rushing in to fix what we perceive as threatening, undermining their own abilities to handle it.

Our inability to gauge resilience is complicated by the fact that much cruelty lies in intersubjective nuances that are equally impossible to grasp, let alone gauge. However, much of the capacity for reparation lies in those nuances as well.

To my mind, singing cruelly revised songs (and encouraging others to sing along) was ongoing abuse, one that called for an intervention. However, "loud singing on the bus" was the only concrete issue that was ever addressed. The victim herself refused any involvement of school authorities, and—as she appears to be thriving—it seems this was the "right call" on her part. (Was it that she could not quite define herself as a victim? That she was handling her "victimization" in ways that adults could not see? That the teacher saw to it that ringleaders got in trouble for unrelated offenses? That—appearances to the contrary—she is burdened by insecurity and secret shame ?)

Interviewing this young woman prompted me to track down, and reconsider, something Clive Seale wrote almost two decades ago:

“in the ebb and flow of everyday interactions, as has been conveyed so effectively in the work of [Erving] Goffman, there exist numerous opportunities for small psychic losses, exclusions and humiliations, alternating with moments of repair and optimism . [Thomas] Scheff (1990) has sought to understand this quality of everyday interaction as consisting of cycles of shame and pride as the social bond is alternately damaged and repaired. The experience of loss and repair is, then, a daily event. In this sense “ bereavement ” (and recovery from it) describes the continual daily acknowledgement of the problem of human embodiment.” (1998)

To adults looking on, cruel song lyrics certainly seem a large "ebb" in the flow of this young student’s life—one requiring intervention. Her story, however, reminds us that as we forge ahead, looking for ways to protect our children against bullying, we must simultaneously enable them to negotiate the "ebbs" in life. A first step in this may simply involve helping them identify the "flow." This is not to lessen active response to bullying, or to sweep it under the rug, but to teach our children to challenge the negative self-narratives that form around bullying experiences. And—perhaps more importantly—to teach them that as bystanders, they contribute to the narratives of others (either implicitly or explicitly). At the risk of sounding Pollyannaish, the identification of counter-factual evidence may go far in challenging this negativity. It turns out, this is precisely what this young women was able to—though a group of friends outside the school environment, who not only raised awareness of, but contributed to, her flow.

Laura Martocci, Ph.D . is a Social Psychologist known for her work on bullying and shame. A former faculty member and dean at Wagner College, her current work centers around identity (re)construction and the transformative potential in change.

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Bullying in a primary school : a case study

Bullying has become a significant issue for schools and one that has attracted the media spotlight. It has also received considerable attention from the research community since the late 1980s following the tradition established through the work of many Scandinavian researchers. Much of the research has been longitudinal and sought to illuminate the experience of children who bullied or were being bullied. There has been considerably less research into teachers' and parents' understanding and experience of bullying between school children. This thesis seeks to rectify that situation by examining the views of Year 5 and 6 pupils, teachers and a sample of parents from a case study primary school. The research was conducted over a period of two years in a school referred to under the pseudonym Nicholas Street. The thesis investigates three questions: first, the meaning that key parties attribute to the term bullying; second, the nature of their experience in the context of the school; and third, their views on how it is handled or resolved. Data were collected through semi-structured interviews and reinterviews with teachers; unstructured and semi-structured interviews, questionnaires and a selection 'game' with pupils and semi-structured interviews and questionnaires with parents. All interviews were audio-taped and transcribed onto a computer database (Hyperqual) and questionnaire responses from pupils were analysed with the support of computer technology (SPSS). The inductive analysis commenced with a case study of a single pupil, Lorraine. This provided the reference point for the structured analysis of bullying issues in the wider context of the school. Findings include: 0 the differing ways that bullying was defined by the parties; 0 the emergent distinction between a relationship that was founded on bullying and an action that might be described as bullying; 0 that bullying usually occurred between pupils in the same class and was not a clandestine activity nor unknown to non-participants (the secretive image); 0 that, although there was a degree of satisfaction reported by all parties concerning methods deployed in handling bullying, there was also inconsistency, confusion and a lack of awareness of policy.

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Chains of tragedy: The impact of bullying victimization on mental health through mediating role of aggressive behavior and perceived social support

1 Institute of Educational Sciences, Hubei University of Education, Wuhan, China

Qiu-jin Zhu

2 School of Philosophy, Wuhan University, Wuhan, China

Associated Data

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Bullying is a worldwide concern for its devastating consequences. The current study focused on bullying victims, examining the effects of being bullied on mental health and the chain of mediating mechanisms among adolescents. Specifically, this study attempts to explain the relationship between bullying victimization and mental health from the perspective of maladaptive behavior and perceived social support.

A total of 3,635 adolescents responded to questions on bullying victimization, aggressive behavior, perceived social support, and mental health measurements including anxiety, depression, and subjective well being scale combined.

(1) Bullying victimization was significantly correlated with aggressive behavior, perceived social support, and mental health, including anxiety, depression, and subjective well being. (2) Bullying victimization not only negatively predicts mental health levels but also has an indirect impact on mental health through three pathways: a separate mediating effect on aggressive behavior, a separate mediating effect on perceived social support, and a chain mediating effect on both.

The present results demonstrate that maladaptive behavior by bullying victims can lead to changes in their perceived social support and mental health problems. Violence begets violence and provides no constructive solutions, instead, produces a tragic chain of victimization. Further implications are discussed accordingly.

Introduction

Bullying victimization is defined as being the target of unwanted aggression and harm in various forms, such as verbal, physical, relational, social bullying, and electronic bullying (Olweus, 1993 ; Sun and Shi, 2017 ). Bullying is a universal phenomenon across different cultures (Chan and Wong, 2015 ; Liu and Lu, 2017 ). Globally, 246 million children reported experiencing bullying and school violence annually (UNESCO, 2019 ). Numerous studies have verified that being bullied has devastating consequences (Peng et al., 2020 ). Those victims of bullying are at an increased risk of low self-confidence, emotional impairment, low level of well being, poor mental health, and even attempts of suicide in both Western and Eastern countries (Cosma et al., 2017 ; Shaheen et al., 2019 ).

Bullying victimization generally leads to a lower level of mental health quality, and this relationship is also influenced by the victims' coping strategy, including the cognition and behavior an individual employs to reduce distress/tension or eliminate stressors (Scarpa and Haden, 2006 ). Previous research has explored bullying victims' coping strategies and the consequences, such as the use of humor, cognitive coping strategies, and help-seeking (Newman et al., 2011 ; Garnefski and Kraaij, 2014 ; Nixon et al., 2020 ; Xie et al., 2022 ). However, previous studies do not adequately consider the multiple coping strategies of bullying victims simultaneously nor examine the underlying relationship among these mechanisms.

According to the general aggression model (GAM), the experience of being bullied as a passive situational factor influences the likelihood of aggressive behavior by exerting influence on aggressive thoughts, angry feelings, and arousal levels, as well as the related appraisal and decision processes. Aggressive action as an outcome influences the social encounter, which usually causes negative social consequences, such as others' responding to the aggression, acting in retaliation, or staying away from the aggressor. At this point, when the individual's reappraisal process is activated, it can influence the present internal state variables (Anderson and Bushman, 2002 ; Allen et al., 2018 ). And the support deterioration model states that stressful events like being bullied deteriorate the perceived availability or the effectiveness of social support, which leads to mental health problems (Barrera, 1986 ). Thus, the current research investigates multiple coping strategies that affect the mental health of bullying victims, and the underlying relationship among these mechanisms. Specifically, this study attempts to examine bullying victims who conduct maladaptive behavior that would lead to a change in their perceived social support and then the level of mental health.

The experience of being bullied harms mental health

Bullying victims are at elevated risk for various externalizing and internalizing problems (Loukas and Pasch, 2013 ). The research found that different forms of bullying (physical, relational, verbal, and cyber) are associated with different harmful behaviors (self-harm, suicide attempts, and suicidal ideation) (Sinclair et al., 2022 ). Being bullied may also result in serious psychological maladjustment and emotional maladaptation. Being the target of bullying leads to the development of hostile attributions and internalizing negative peer messages, and victimization triggers internalized issues in individuals, such as anxiety, depression, low self-esteem, and feelings of loneliness (Loukas and Pasch, 2013 ; Cross et al., 2015 ).

In recent years, researchers started to examine the impact of bullying on individual well being (Varela et al., 2018 ; Miranda et al., 2019 ). A cross-country study of 47,029 children and adolescents in 15 countries found that bullying had a significant negative impact on subjective well being across countries and at different ages (Savahl et al., 2019 ). In China, 636 boarding students of grades 4–6 in rural primary schools were investigated by questionnaire, including school bullying, subjective well being, school bonding, and positive psychological capital, and school bullying was negatively correlated with school bonding and subjective well being (Wu et al., 2022 ).

The dual-factor model of mental health suggests that the concept of a good mental health condition includes the absence of negative indicators (e.g., depression, anxiety, negative affect) and the presence of positive indicators (e.g., subjective well being, life satisfaction, positive affect), which is a more comprehensive and accurate assessment of individual mental health (Greenspoon and Saklofske, 2001 ; Suldo and Shaffer, 2008 ). And based on the above analysis, this study proposes H1 : Bullying victimization negatively predicts mental health levels, including levels of anxiety, depression, and subjective well being.

The impact of bullying victimization on mental health through the mediation effect of maladaptive behavior

Several studies have found victimization increases the risk of maladaptive behavior. Individuals who have suffered from bullying usually have no reasonable way to resolve the accumulation of psychological problems, such as panic, social anxiety, and depression, and this can generate explosive attacks and illegal anti-social behavior (Li, 2016 ; Liu and Lu, 2017 ). The longitudinal research from different cultures also showed that victimization has a long-term negative impact and produces maladaptive reactions. Bullying victims exhibit obstacles in interpersonal communication and produce behavior deviation (Liu and Zhao, 2013 ), and the experience of being bullied could significantly predict aggressive behavior, taking revenge, and getting involved in illegal and violent crimes and violent crimes in adulthood (Jackson et al., 2013 ; DeCamp and Newby, 2015 ).

Maladaptive behavior of bullying victims could produce mental health issues. Bullying victims scored higher on hostile interpretation, anger, retaliation, and ease of aggression than the other children (Camodeca and Goossens, 2005 ), and aggressive acts that would occur as impulsive behavior to cause harm to the source of frustration and defend themselves were positively associated with generalized anxiety symptoms and depressive symptoms (Pederson et al., 2018 ).

The experience of being bullied, maladaptive behavior, and mental health appeared to be closely linked. The bullying victims who engage in aggressive behavior are more likely to attribute hostile intent in ambiguous situations and react more aggressively to peer conflict, which further elicits peer rejection and behavior problems, and are the most maladapted and in greatest need of intervention (Bettencourt et al., 2013 ). Studies have found evidence that depression, anxiety, and loneliness were characteristics of aggressive victims (Shao et al., 2014 ); however, there is also some data which provide no evidence of unique social-emotional dysfunction of aggressive victims. Thus, properly accounting for potentially confounding influences on the internalizing problems is needed (O'Connor et al., 2019 ; O'Connor, 2021 ). The impact of victimization on mental health through maladaptive behavior needs to be examined further. As a result, this study proposes Hypothesis H2 : Bullying victimization can impact mental health levels through the mediating role of aggressive behavior.

The impact of bullying victimization on mental health through perceived social support

Social support is defined as social interactions or relationships that provide individuals with the assistance or support that embed individuals within a social system to provide love, care, or a sense of attachment to a valued social group. And perceived social support is the belief that these helping behaviors will occur when needed (Norris and Kaniasty, 1996 ). If individuals believe they are loved and valued and can depend on others, they are more likely to have help-seeking behavior (Lakey and Cohen, 2000 ).

Perceived social support may be viewed as a variable that has wide-ranging effects on physical and mental well being (Scarpa and Haden, 2006 ). Research reported that adolescents' perceived social support was significantly negatively correlated with suicidal ideation in cyberbullying victimization (Xu et al., 2021 ). The research which explored the perceived social support in crime victims proposed that chronic victimization erodes the victim's perception of social support and in turn, leads to heightened levels of distress and is detrimental to the victim's well being (Yap and Devilly, 2004 ).

Even worse, it has been found that most bullying victims do not actively report these experiences to parents and teachers, and do not seek help in the case of low perceived social support, which creates a vicious cycle of bullying and victimization (Haataja et al., 2016 ; Yablon, 2017 ). The data indicated that only one in four chronically victimized students turned to school staff for help, and 30% of bullying victims kept silent about their problems (Smith and Shu, 2000 ; Sitnik-Warchulska et al., 2021 ).

Thus, understanding the social context in which bullying occurs and the individual's perceived social support in different sources is vital to comprehend both the unique associations between bullying victims and mental health, and facilitate the development of prevention and intervention activities (Noret et al., 2020 ). Based on the above literature, this study proposes Hypothesis H3 : Bullying victimization can impact mental health levels through the mediating role of perceived social support.

The relationship between maladaptive behavior and perceived social support

Evidence suggests that the motivation for aggressive behavior is resorting to control or getting higher social status among peers, but it is the distorted relationship chains (Juvonen and Graham, 2014 ; Sun and Shi, 2017 ). The victim's aggressive behavior could be from mimicking the parents and other adults in the family or social setting (Bandura, 1974 ). Some of them are isolated from social groups during early childhood, forming interpersonal bonds through inappropriate behaviors, such as aggression (Olweus, 1978 ). Published data have identified that bullying victims with aggressive behavior do not share any social benefits with the high social status of bullies, but they have a higher level of distress and peer rejection (Juvonen et al., 2003 ; Chen and Zhang, 2018 ).

Meta-analysis summarizes that bullying victims who engage in aggressive behavior are concurrently associated with a range of adjustment difficulties, including loneliness, school-related fear, anxiety or avoidance, low self-esteem, and fear or avoidance of social interactions (Reijntjes et al., 2010 ). The feeling of neglect in peer relationships may impede their ability to build solid prosocial ties with others and limit their opportunities to gain sufficient social support. For instance, children engaging in bullying perpetration often reported a low quality of parental relationships, which are associated with further psychosocial difficulties in adolescent development (Sitnik-Warchulska et al., 2021 ). Another study in China also found a significantly negative correlation between bullying and perceived social support (Yang, 2020 ). The gradual alienation from peers may also impact bullying victims' mental health, such as anxiety and depression. On this basis, this study proposes Hypothesis H4 : Aggressive behavior and perceived social support play a chain mediating role between bullying victimization and mental health.

Therefore, the current study explores the impact of the experience of being bullied and their maladaptive behavior on mental health and whether perceived social support plays a vital role in the relationship. We investigated the chain mediating effect of bullying victims' aggressive behavior and perceived social support in the relationship between the experience of being bullied and mental health among adolescents. From the adaptation perspective to understand the perplexing role of bullying victims, we try to underline the mechanism of bullying victims' dysfunctional behavior and provide empirical evidence for intervention programs. The relationship path diagram proposed in this study is illustrated in Figure 1 as follows.

Relationship path map of bullying victimization, aggressive behavior, perceived social support, and mental health.

Materials and methods

Participants and procedure.

Eight middle schools were randomly selected in the Hubei province of China. The research ethics committee approved the study at the Hubei University of Education, and it was conducted with the consent of the school and the adolescents' guardians. The students were told that none of their responses would be revealed to anyone and that they could stop participating at any time without penalty. All participants completed an online questionnaire in Chinese. A total of 3,635 valid online questionnaires were obtained. Among students who participated in the survey, 1,757 were male, and 1,878 were female, 968 were studying in grade junior one, 930 were in grade junior two, 583 were in grade junior three, and 547 were in grade senior one, and 607 were in grade senior two. The demographic information of the participants is shown in Table 1 .

Demographic information in the bullying victimization score of adolescents.

Measurements

Bullying victimization.

The bullying victimization is measured by the Olweus Bully/Victimization Questionnaire (OBVQ). The Chinese version of OBVQ which was adopted in current research, was revised with good validity and reliability among adolescents (Xie et al., 2015 ). The OBVQ is comprised of three dimensions namely physical bullying, verbal bullying, and relational bullying. The scale has 12 items. Each item is rated on a six-point Likert scale ranging from 1 (never happened this semester) to 6 (happened every day this semester). The higher score of OBVQ represents a higher degree of victimization experience. In this study, the Cronbach's α value of the questionnaire was 0.93.

Aggressive behavior

The aggressive behavior was measured by a tool to measure aggressive behavior extracted from externalizing problem behavior for adolescents developed by Zhang et al. ( 2011 ). In this study, seven questions were selected and adapted as required, such as “fighting ”, “destroying public property or other people's property for no reason”, “verbally abusing others”, etc., using a five-point Likert scale. The subjects were asked to rate the frequency of the occurrence of these behaviors in the last six months. The mean scores of the seven items were calculated with higher scores indicating more aggressive behavior. Previous studies have shown that the questionnaire has good reliability and validity in the Chinese cultural context (Yu et al., 2011 ). In this study, the Cronbach's α value of the questionnaire was 0.71.

Perceived social support

Zimet et al. ( 1988 ) developed the Multidimensional Scale of Perceived Social Support (MSPSS) to measure the perceived adequacy of social support received from family, friends, and significant others. The MSPSS includes 12 items (e.g., “I can count on my friends when things go wrong”). Respondents report their agreement on a 7-point Likert-type scale with higher total score meaning higher perceived social support. Previous studies showed that the scale had a good reliability and validity when used with Chinese adolescents (Yang and Han, 2021 ). The Cronbach's α value of the Chinese MSPSS used in this study was 0.96.

The Chinese version of the 9-item Patient Health Questionnaire (PHQ-9) was used to measure the severity of depressive symptoms. A total score ranged from 0 to 27 (higher points indicating more severe depressive symptoms), with each item that can earn 0 to 3 points (0 = Not at all to 3 = Nearly every day). Depressive symptoms were classified by severity into five groups, namely, minimal (scores of 0-4), mild (5-9), moderate (10-14), moderately severe (15-19), and severe (20-27) (Kroenke et al., 2001 ). In this study, the average depression score was 3.05, and the standard deviation was 4.56, indicating that the participants' overall depressive symptoms were relatively mild. The Chinese version of PHQ-9 has been widely used, and previous studies showed that the scale had good reliability and validity when used with Chinese adolescents (Leung et al., 2020 ). In this study, the Cronbach's α value of the questionnaire was 0.93.

Anxiety symptoms were measured using the Chinese version of the Generalized Anxiety Disorder scale (GAD-7; Tong et al., 2016 ). Each item has four response options ranging from 0 to 3 (0 = Not at all to 3 = Nearly every day). Each participant can obtain a total score from 0 to 21, with higher score indicating more severe anxiety symptoms. Cut points of 5, 10, and 15 might be interpreted as representing mild, moderate, and severe levels of anxiety on the GAD-7 (Spitzer et al., 2006 ). In this study, the average depression score was 2.98, and the standard deviation was 3.94, indicating that the participants' overall depressive symptoms were relatively mild. The Chinese version of GAD-7 can be used in the Chinese context with good reliability and validity (Zeng et al., 2013 ; Tong et al., 2016 ). This scale had good internal consistency, with a Cronbach's α value of 0.93.

Subjective well being

Subjective well being was measured using the two components: Index of well being and Index of General Affect (Campbell, 1976 ). Ratings for each item in the overall index ranged from 1 to 7. The Index of General Affect consists of eight items that describe the connotation of emotions at different levels, while the Index of well being had only one item. The total score of the Index of Well being and the Index of General Affect was calculated by adding the average scores of its two parts (weight 1.1), with scores ranging from 2.1 to 14.7. In this study, the average subjective well being score was 12.30, and the standard deviation was 3.18.

Common method biases

All measurement items were processed by non-rotational exploratory factor analysis, applying the Harman single-factor test method. Based on the results of the analysis, a total of 3 common factors with eigenvalues greater than 1 were extracted, and the first common factor could be used to explain 38.77% of the total variation, which did not reach the standard threshold of 40%. Thus, this study has no unacceptable deviation caused by the same method for data collection (Podsakoff et al., 2003 ).

Descriptive statistics and correlation coefficients of variables

Table 2 shows the results of descriptive statistics and correlation data of the research variables. Bullying victimization not only shows significant positive correlation with aggressive behavior, depression, and anxiety, but also shows significant negative correlation with perceived social support and subjective well being. Aggressive behavior not only shows a significant positive correlation with depression and anxiety, but also shows a significantly negative correlation with perceived social support and subjective well being. Perceived social support shows a significant positive correlation with subjective well being, and a significant negative correlation with depression and anxiety. Moreover, depression is positively correlated with anxiety, and negatively correlated with subjective well being. Last, anxiety has a significant negative correlation with subjective well being.

Correlation analysis of study variables.

M, Mean; SD. standard deviation.

** P <0.01.

Bullying victimization and mental health: Chain mediating effect test

Chain mediational analysis explored the impact of bullying victimization on mental health through aggressive behavior and perceived social support. Bootstrapping analyses (5,000 re-samples) were conducted for testing the mediational model (Hayes, 2013 ).

The results showed that the total effect (βs = 0.456, 0.434, and −0.336, t s = 29.287, 27.522, and −20.375, All p < 0.001) and the direct effect (βs = 0.318, 0.295, and −0.162, t s = 19.722, 18.041, and −9.822, All p < 0.001) of bullying victimization on depression, anxiety, and subjective well being were all significant. Bullying victimization significantly predicts aggressive behavior (β = 0.264, t = 16.507, p < 0.001), and aggressive behavior significantly predicts depression, anxiety, and subjective well being (βs = 0.118, 0.142, and –.093, t s = 7.992, 9.531, and −6.169, All p < 0.001), indicating that aggressive behavior played a mediating role between bullying victimization and depression, anxiety, and subjective well being separately. Similarly, bullying victimization significantly predicts perceived social support (β = −0.332, t = 20.800, p < 0.001), and perceived social support predicts depression, anxiety, and subjective well being (βs = −0.281, −0.264, and 0.391, t s = −18.452, −17.149, and 25.245, All p < 0.001), indicating that perceived social support played a mediating role between bullying victimization and depression, anxiety, and subjective well being separately. Meanwhile, aggressive behavior can also predict perceived social support (β = −0.110, t = −6.898, p < 0.001). Therefore, aggressive behavior and perceived social support had a chain mediating effect between bullying victimization and depression, anxiety, and subjective well being separately among Chinese teenagers ( Tables 3 – 6 ).

Regression model of the effect of bullying victimization on mental health among Chinese teenagers.

Results of the mediating effect analysis of bullying victimization and depression, anxiety, and subjective well being in Tables 4 – 6 showed that Bootstrap's 95% CI of total indirect effect did not contain 0 [All Bootstrap 95% CI: 0.114, 0.166; 0.115, 0.165; −0.202, −0.149], accounting for 30.26, 32.03, and 51.79% of the total effect. Notably, three indirect effect pathways influenced the relation of bullying victimization and depression, anxiety, and subjective well being. First, the mediating effect values of Path1 (Bullying victimization → Aggressive behavior → Depression, Anxiety, and Subjective well being) were 0.032, 0.039, and −0.026 separately, accounting for 7.02, 8.99, and 7.74% of the total effect. Second, the mediating effect values of Path2 (Bullying victimization → Perceived social support → Depression, Anxiety, and Subjective well being) were 0.097, 0.092, and −0.136 separately, accounting for 21.27, 21.20, and 40.48% of the total effect. Third, the mediating effect values of Path3 (Bullying victimization → Aggressive behavior → Perceived social support → Depression, Anxiety, and Subjective well being) was 0.009, 0.008, and −0.012 separately, accounting for 1.97, 1.84, and 3.57% of the total indirect effect. Note that the chain mediating model is shown in Figures 2A–C .

Mediating effect analysis of bullying victimization and depression.

Mediating effect analysis of bullying victimization and subjective well being.

(A) The mediating effect path map of bullying victimization and depression. * p < 0.05, ** p < 0.01, and *** p < 0.001. (B) The mediating effect path map of bullying victimization and anxiety. * p < 0.05, ** p < 0.01, and *** p < 0.001. (C) The mediating effect path map of bullying victimization and subjective well being. * p < 0.05, ** p < 0.01, and *** p < 0.001.

Mediating effect analysis of bullying victimization and anxiety.

The initial objective of the research was to identify the impact of bullying victimization on mental health, and the serial mediating roles of aggressive behavior and perceived social support among adolescents. As indicated by the results of this study, the experience of being bullied significantly increased the level of mental health issues, such as higher levels of anxiety and depression, and lower levels of subjective well being. The relationship results are consistent with previous studies and verified Hypothesis 1 in the study (Juvonen and Graham, 2014 ).

The present study also discovered that aggressive behavior as a maladaptive reaction had significant mediating effects on the relationship between the experience of being bullied and mental health, with its mediating role accounting for 7.02, 8.99, and 7.74% of the total effect for anxiety, depression, and subjective well being. The Hypothesis 2 is confirmed. In addition, these results verified the negative outcome of aggressive behavior for bullying victims, which demonstrated that bullying victims' crude responses would aggravate the mental health issue. Violence begets violence provides no constructive solutions.

Meanwhile, the current study also found significant mediating effects of perceived social support in the relationship between the experience of being bullied and mental health, with its mediating effect accounting for 21.27, 21.20, and 40.48% of the total effect for anxiety, depression, and subjective well being. The present results are congruent with the latest research in the area of bullying victims and prove Hypothesis 3 (Lin et al., 2020 ). Perceived social support from parents, friends, and other relatives is a vital protective factor to disengage bullying victims from mental health issues.

Previous studies do not adequately consider the multiple coping strategies of bullying victims simultaneously and examine the underlying relationship among these mechanisms. The current study explored the impact of bullying victims' aggressive behavior to perceived social support, and whether aggressive behavior and perceived social support serially mediated the relationship between bullying victimization and mental health. The aggressive behavior of bullying victims may produce feelings of isolation in interpersonal relationships and is harmful for victims' mental health status. The results support Hypothesis 4 that the higher level of bullying victimization would raise the possibility of mental health issues through maladaptive aggressive behavior and lower the level of perceived social support. It has also been confirmed that there is a close correlation between aggressive reaction and perceived social support (Yang, 2020 ). The current study's outcome revealed the basic psychological processes of an individual being bullied and helped us in understanding how their variety of responses led to disastrous outcomes. Teenager bullying victims may adopt simple and rough maladaptive behavior, which aggravate the individual's mental health problems. This process will also weaken the individual's perception of positive resources. This mechanism is a kind of interlocking “Tragic Chain”.

The research revealed the process of how bullying victim's maladaptive coping strategies generates mental health issues through aggressive behavior and perceived social support in a large sample of Chinese adolescents. It is a risk factor for the mental health development of teenagers with the experience of being bullied. That is, the impulsive aggressive behavior of bullying victims would reduce their perceived social support and put their mental health status in danger. It implied that a violent response to violence produces chains of tragedy in bullying situations. Recent research in the related area also discovered the similar phenomenon that forgiving rather than revenge can regain the feeling of humanity after the victimization experience (Schumann and Walton, 2022 ).

Furthermore, the results of the present study support the implementation of bully prevention programs and actions, including: enhancing individual strategies effectively counteract bullying, and increasing empathy toward victims; attaching importance to the social support from peers, school staff, parents, and other stakeholders, guide them to improve assistance afforded to victims, and other relative interventions (Salmivalli et al., 2011 ; Roca-Campos et al., 2021 ). The mediating chain effect of the study sheds light on the underlying processes that the victim's maladaptive behavior would reduce the perceived social support, and then deteriorate mental health. The increasing understanding of these processes supports detailed application to reduce the insensitivity of social resources and mental health problems caused by the experience of being bullied and, through modifying the maladaptive aggressive behavior, alleviates the bullying's negative influence to a certain extent, then breaks the chains of tragedy.

Limitations and future orientation

The current research has some deficiencies and limitations, which may be addressed in the future. First, the present study was a cross-sectional design study, it cannot clarify the causal relationship between variables. Therefore, further research should be conducted to better clarify the relationship between variables through experimental design and longitudinal study. Second, the current research results are in the context of Chinese cultural background. In a collective culture, individuals' survival and development needs depend more on interpersonal relations (Yum, 1988 ). Future studies could explore whether there is a cultural difference in the mechanism of maladaptive reactions of bullying victims.

Bullying and victimization is a growing area of research in psychology. The present study provides further scientific evidence for intervention after the experience of being bullied at the behavioral and cognitive levels. The Chains of Tragedy of bullying victims who conduct maladaptive behavior would lead to a change in their perceived social support and mental health problems, reminding us to draw attention to the sequential effect of multiple variables at work in bully prevention.

Data availability statement

Ethics statement.

The studies involving human participants were reviewed and approved by Ethics Committee of Hubei University of Education. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.

Author contributions

YG: conceptualization, collected the data, writing—review and editing, data curation, and worked on the final version of the manuscript. XT: writing—review and editing, data curation, and worked on the final version of the manuscript. QZ: conceptualization, collected the data, writing—formal analysis, data curation, and worked on the final version of the manuscript. All authors contributed to the article and approved the submitted version.

This work was supported by Ministry of Education of the People's Republic of China Humanities and Social Sciences Youth Foundation under Grant (No. 19YJCZH044).

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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• Published: 26 May 2024

Effects of expanded adverse childhood experiences including school bullying, childhood poverty, and natural disasters on mental health in adulthood

• Natsu Sasaki 1 ,
• Kazuhiro Watanabe 2 ,
• Yoshiaki Kanamori 3 ,
• Takahiro Tabuchi 4 , 5 ,
• Takeo Fujiwara 6 &
• Daisuke Nishi 1  

Scientific Reports volume  14 , Article number:  12015 ( 2024 ) Cite this article

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The study aimed to examine the association of expanded adverse childhood experiences (ACEs) with psychological distress in adulthood. The data from nation-wide online cohort was used for analysis. Community dwelling adults in Japan were included. The ACEs was assessed by 15 items of ACE-J, including childhood poverty and school bullying. Severe psychological distress was determined as the score of Kessler 6 over 13. Multivariable logistic regression analysis was conducted, by using sample weighting. A total of 28,617 participants were analyzed. About 75% of Japanese people had one or more ACEs. The prevalence of those with ACEs over 4 was 14.7%. Those with ACEs over 4 showed adjusted odds ratio = 8.18 [95% CI 7.14–9.38] for severe psychological distress. The prevalence of childhood poverty was 29% for 50–64 year old participants and 40% of 65 or older participants. The impact of childhood poverty on psychological distress was less than other ACEs in these age cohorts. Bullying was experienced 21–27% in young generations, but 10% in 65 or older participants. However, the impact on psychological distress in adulthood was relatively high in all age groups. ACEs have impacted mental health for a long time. Future research and practice to reduce ACEs are encouraged.

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Introduction.

Adverse childhood experiences (ACEs) are traumatic events that children and adolescents under 18 years of age have experienced 1 . People with a history of ACEs are at greater risk of deterioration in physical and mental health 2 , 3 , and ultimately premature mortality 4 , 5 . The cumulative effect of a diverse range of ACEs can impact health outcomes in adulthood and far beyond from life-course perspectives 6 , 7 . Studies increasingly establish evidence that ACEs leads to develop mental health issues, including depression, substance misuse, and suicide 8 , 9 , 10 , 11 . A World Health Organization (WHO) study revealed that ACEs were associated with all lifetime DSM–IV disorders worldwide 12 . These associations are explained by both neurobiological development and external factors 13 . For example, early life exposure to chronic stress causes greater activation of the hypothalamic-pituitary-adrena (HPA) axis, and high levels of inflammation, resulting in deficits of cognitive and affective functioning and increased allostatic load 14 , 15 . ACEs also lead to impaired social functioning, such as lack of social support 16 , 17 , 18 .

ACEs traditionally included childhood maltreatment and household dysfunction. For example, physical neglect, characterized by a caregiver's failure to provide for a child's basic physical needs. Recently, the concept has been expanded to include community-level and social factors, such as school bullying and economic hardship 19 , 20 , 21 , 22 , 23 . Furthermore, ACEs can differ by race, culture, and era 19 , 22 . An ACE scale for the Japanese context (ACE-J) has been developed to assess expanded ACEs reflecting the Japanese situation 7 and its potential benefit of use is to capture the influence of expanded and culturally familiar ACEs on outcomes. For example, Japan has a high prevalence of both school bullying victimization and natural disasters compared to other countries 24 , 25 . Childhood poverty is also considered an important factor as a root cause of ACEs from life-course perspective 26 . Although the relationship between the conventional ACEs and mental health issues in adulthood have been well investigated, the more recent potential constructs of ACEs should be further explored 27 .

Few studies have examined long-term effects of a wide range of ACEs in Asians. In Japan, the association of conventional ACEs with mental health was last reported in 2011 28 . A scoping review about different types of ACEs from articles (n = 1281) showed that less articles reported expanded ACEs (e.g., household financial hardship; 18%, victimization by peers; 10%, exposure to natural disasters; 2%) 23 . Besides, over 60% of the articles related to ACEs published from United States 23 . This disproportionate evidence motivates researchers to examine long-term impact mental health by expanded ACEs in various countries. The understanding of its association in ethnic groups of a particular culture can lead to the development and implementation of locally sensitive countermeasures 29 . Moreover, empirical evidence about the association of the expanded concept of ACEs on mental health would benefit specifically to evaluate the impacts of each ACE.

The aim of this study was thus to examine the association of expanded ACEs with mental health in adulthood in Japanese community sample. The impact of childhood poverty and school bullying on mental health was investigated, considering demographic indicators.

Research design

For this research, we utilized data from the Japan COVID-19 and Society Internet Survey (JACSIS), an ongoing nationwide online cohort study conducted in Japan 30 . JACSIS cohort study began in August 2020. The JACSIS included community-dwelling individuals aged 15–79 years. The baseline sample of JACSIS was collected in 2020, consisting of 28,000 participants. In 2022, a follow-up survey was conducted for the participants from 2020 survey or 2021 survey, and new participants were also invited. This resulted in a total of 32,000 participants in the 2022 survey. This study employed a cross-sectional design using the JACSIS 2022 data, which was collected in September 2022.

Participant recruitment

To recruit participants, we utilized email messages to request survey participation from a research panel maintained by Rakuten Insight, Inc. This private company have information about over 2.2 million individuals aged 15 to 79 years with diverse sociodemographic backgrounds, representing the national population across all 47 prefectures of Japan. We employed a simple random sampling method based on sex, age, and prefecture category in accordance with the official Japanese demographic composition as of October 1, 2019, to select potential participants. Those who agreed to participate were provided access to a designated website. Participants had the option to skip questions or discontinue the survey at any point.

Data quality management

To ensure the validity of the data, we excluded respondents who exhibited discrepancies or provided artificial/unnatural responses. Specifically, we used three question items to identify such responses: "Please choose the second from the bottom," "choosing positive in all of a set of questions for using drugs," and "choosing positive in all of a set of questions for having chronic diseases." A total of 3,370 respondents were found to have provided such responses and were subsequently excluded from the study.

Participants

Our study included community-dwelling individuals in Japan who were over 18 years old and had complete data. Participants who were under 18 years old were excluded (n = 13).

Measurement variables

Expanded adverse childhood experiences.

We assessed Adverse Childhood Experiences (ACEs) using the Adverse Childhood Experiences Japanese version (ACE-J) questionnaire 7 . The ACE-J questionnaire was developed to measure individuals' exposure to various adversities during their childhood in Japan. For example, incarcerated household member was excluded, reflecting Japanese culture. Each category of adversity was represented by a single item, except for parental loss, which included both parental death and divorce or separation. In addition to the CDC-Kaiser ACE questionnaire 1 , the ACE-J included, childhood poverty, overcontrol, school bullying, hospitalization due to chronic disease, and exposure to life-threatening natural disasters. The ACE-J questionnaire consisted of a total of 15 items (parental death, parental divorce, mental illness in the household, substance abuse in the household, mother treated violently, physical abuse, physical neglect, emotional abuse, emotional neglect, childhood poverty, overcontrol [“I always felt suffocated because my parents did not respect my opinion”], school bullying, sexual abuse, hospitalization due to chronic disease, natural disaster), and participants were asked whether they had experienced each adversity before the age of 18. The response options were "Yes" or "No." One item related to emotional neglect was a reversed question, specifically assessing whether participants felt loved by their parents. To calculate the total number of ACEs experienced, the score of the reversed item was reversed, and the summed score of all ACE items was used. The ACE-J questionnaire was not validated in publication.

Psychological distress

Psychological distress refers to a broad range of emotional and psychological symptoms or experiences that can cause discomfort, suffering, or impairment in daily functioning.　Psychological distress was measured by The Kessler Psychological Distress Scale (K6), which has been widely used and is preferred for screening for any DSM-IV mood or anxiety disorder. K6 includes six items that measure the frequency of psychological distress symptoms experienced by participants over the past 30 days 31 . Participants provide responses on a scale ranging from 0 (none of the time) to 4 (all the time). Previous studies have reported satisfactory internal reliability and validity for Japanese version of K6, showing that performance in areas under receiver operating characteristic curves (AUCs) was 0.94 detecting DSM-IV mood and anxiety disorders 32 . K6 scores over 13 are regarded as a serious mental distress 31 , 33 , 34 . Prevalence of people with over 13 scores of K6 was reported 4% in Japan 35 .

Demographic characteristics

The sociodemographic characteristics of the participants were assessed, including age, sex, educational attainment (categorized as less than high school, vocational/college, undergraduate, graduate or over), marital status (categorized as married, single/divorced), household income (categorized as < 3 million yen, 3–5 million yen, 5–8 million yen, 8–10 million yen, over 10 million yen, or no response/unknown), and working status (categorized as paid work, no paid work, or students).

Statistical analyses

First, the descriptive statistics were estimated. These included the prevalence of ACEs and severe psychological distress and the coexistence of the ACEs. To address a potential sampling bias due to the internet survey, a propensity score for participation in the internet survey was calculated. We utilized a demographic distribution of a national paper-based survey, the Comprehensive Survey of Living Conditions of People on Health and Welfare (CSLCPHW). Using sex and age group stratifications (sex × age groups = 14 strata), we calculated the propensity score separately for each stratum. The mean of the score was group-mean centered and was set to 1.0 within each stratum. Residential area, marital status, education, home-ownership (household), self-rated health and smoking status, which were available both CSLCPHW and JACSIS, were used for the model to calculate the propensity scores. The inversed propensity score was used as the sampling weight for the calculation of the prevalence of the ACEs and psychological distress. The difference in the prevalence of ACEs among stratified categories (sex and age groups) was tested using a chi-square test. Also, the summed number of ACEs was tested using a t-test in sex and one-way analysis of variance (ANOVA) in age category. The coexistence of the ACEs was presented as a matrix.

For the main analysis, the associations of ACEs with severe psychological distress were assessed by using logistic regression analysis, adjusted by age, sex, marital status household income, work, and educational attainment. The sampling bias was also adjusted by the inversed propensity score. Additionally, the subgroup analyses were conducted stratified by sex and age categories. The statistical significance for all analyses in this study is set at 0.05 (two-tailed), and 95% CIs were calculated. SPSS 28.0 (IBM Corp., Armonk, NY, USA) Japanese version was used.

Ethics approval and consent to participate

The study was reviewed and approved by the Research Ethics Committee of Graduate School of Medicine/Faculty of Medicine, The University of Tokyo (no. 2020336NI-(3)) and by the Research Ethics Committee of the Osaka International Cancer Institute (no. 20084). All methods were carried out in accordance with the Declaration of Helsinki.

Informed consent

Online informed consent was obtained from all participants with full disclosure and explanation of the purpose and procedures of this study. The panelists had the option to not respond to any part of the questionnaire and the option to discontinue participation in the survey at any point.

A total of 28,617 community dwelling people was included in the analysis. The participants’ characteristics are presented in Table 1 . The mean age was 48 years old (standard deviation [SD] = 17.1). Majority demographics included those who were married (62%), with undergraduate level of educational attainment (46%), and with paid work (65%).

The sample weighted prevalence of expanded ACEs is presented in Table 2 . The overall prevalence of expanded ACEs was varied from lowest (physical neglect = 3.2%) to highest (emotional neglect = 38.5%). The mean of summed number of ACEs was 1.75 (SD = 1.94). The histogram of the summed number of ACEs is presented in Supplementary Fig.  1 . The prevalence of those with ACEs over 4 was 14.7%. The prevalence of childhood poverty and school bullying was 26.3% and 20.8%, respectively.

For sexual difference, the mean of the summed number of ACEs was larger for females (1.85 vs 1.65; p < 0.001). Sexual abuse was particularly experienced more in female populations (6.9% vs 1.8%). For age difference, the mean of the summed number of ACEs was highest in age 35–49 years old (1.87 [SD 2.03]). Those over 65 years old showed lowest score of ACEs (1.55 [SD 1.73]). Among those over 65 years old, the prevalence of parental death (21%) and childhood poverty (40%) were higher than other age category (p < 0.001), and parental divorce (7%) was lower (p < 0.001).

Table 3 shows the prevalence of severe psychological distress (K6 ≥ 13), which was adjusted for weighed scores. The overall prevalence was 10.4%. The prevalence of severe psychological distress increased as the number of ACEs increased. The highest prevalence of high distress was observed in those with ACEs over 4 in ages 18–34 years old (40.7%). In the group with the same number of ACEs, younger groups showed significantly high prevalence of severe distress compared to older groups (p < 0.001). The significant group difference of sex was not shown in the group with 2 or more ACEs.

The result of the associations of ACEs with severe psychological distress is presented in Table 4 , using a logistic regression analysis. Almost all individual ACEs, except parental death, were significantly associated with high distress in adulthood in adjusted model (odds ratio ranging from 1.23 to 4.01). The adjusted odds ratio of school bullying, hospitalization due to chronic disease, and natural disaster was 3.04, 2.67, and 2.66; respectively. The odds of high distress increased as the number of ACEs increased; those with ACEs over 4 showed adjusted OR = 8.18 [95% CI: 7.14–9.38].

The result of logistic regression analysis which was stratified by sex and age category is shown in Table 5 . Adjusted odds ratio was rather higher in male than female in physical neglect and sexual abuse (aOR = 4.68 [3.68–5.94], aOR = 4.05 [3.06–5.36]; respectively). In age category, physical abuse and physical neglect were highly impacted on the prevalence of high distress among those over 65 years old (aOR = 5.60 [2.87–10.93], aOR = 6.27 [3.41–11.55]; respectively), compared to other age group. However, parental death, parental divorce, and childhood poverty showed lower odds among those over 65 years old and 50–64 years old, compare to 18–34 years old and 35–49 years old.

Supplementary table 1 shows the relationship between ACEs, which was adjusted for weighted scores. We found high comorbidity of ACEs; for example, those who experienced physical abuse also experienced emotional abuse (75%), overcontrol (68%), and emotional neglect (65%).

This study presented the high prevalence of expanded ACEs in Japan and its strong impact on mental health in adulthood. The mean of summed number of ACEs as measured by expanded ACEs scoring customized for Japanese people was 1.75. The prevalence of those with ACEs over 4 was 14.7% and they significantly showed high odds on severe psychological distress in adulthood, compared to those with none ACE (aOR = 8.18 [95% CI 7.14–9.38]). Childhood poverty showed lower odds among those over 65 years old and 50–64 years old compared to other ACEs. Bullying relatively showed higher odds among all age categories, with some difference of prevalence across age category.

About 75% of participants had one or more ACEs in this study. Reports of worldwide prevalence of ACEs are lower, including 62% in U.S. 36 and 47% in Europe 37 , by measuring 11 items of ACEs in both studies. A systematic review of a ACE-related study with a large sample reported that a pooled prevalence of individuals with one ACE was 23.5% in Europe and 23.4% in North America, and those with two or more was 18.7% in Europe and 35.0% in North America 38 . However, in expanded ACE study (The Philadelphia Urban ACE Study), a prevalence of 83.2% had at least one ACE and 37.3% experienced four or more ACEs, measured by 14 items with additional stresses including bullying 39 . These studies support our findings of prevalence of expanded ACEs.

Among 15 of the expanded ACEs, emotional neglect, childhood poverty, and bullying showed highest prevalence (39%, 26%, and 21%, respectively). A previous study from 2002–2004 using Japanese data reported that parental death (12%), parental divorce (11%), family violence (10%), and physical abuse (8%) were the most prevalent, but neglect was reported less (2%) 28 . The prevalence of emotional neglect in this present study (26%) may be over reported. When compared to recent studies, the prevalence of psychological neglect was 11.6% 40 . One possible reason was that emotional neglect in our study was measured by an inverse item (i.e., “I felt loved by my parents.”). Reversed items in surveys sometimes cause measurement problems due to misresponses 41 . Since this data was obtained online, the misresponse or careless answer may be more likely to occur compared to in-person interviews. However, based on the finding that there is a significant positive association between the presence of emotional neglect and severe psychological distress, it is possible that emotional neglect is this prevalent in Japan. Possible factors contributing to a high prevalence of emotional neglect might include Japan's traditionally reserved emotional culture (e.g., less expression of positive feelings 42 ), insufficient emotional support due to parental employment and household issues, as well as inadequate systems for early detection and protection, potentially resulting in an elevated prevalence rate. The expected level of “loved” for Japanese may be higher than the standard family relationship.

All 15 of the individual ACEs showed the negative impact on mental health, after adjusting covariates. Physical neglect and physical abuse showed highly negative associations (aOR = 4.01, 3.65; respectively). This result was partially consistent with the previous Japanese WHO survey data, which showed parental mental illness and physical abuse strongly affected the onset of mood disorder 28 . With a few exceptions 43 , few paper suggested that physical neglect had a significant impact on mental health; but we should note that those with physical neglect has high comorbidity of ACEs (e.g., childhood poverty, emotional abuse/neglect) in this study. Many studies suggested that emotional abuse and neglect had great impacts on mental health 44 , 45 , 46 , 47 . Such comorbidity might strengthen the impact of physical neglect. Consistent with Tzouvara and colleagues (2023), this study demonstrated that all ACEs can negatively impact mental health, and ACEs can manifest differently in different populations 27 .

In this study, school bullying impacted on deteriorated mental health in adulthood among all age categories, although the prevalence of experience was lower in older generations. School bullying have serious and lasting negative impacts on mental health, including depression 48 , 49 , 50 , 51 , anxiety 48 , 50 , 51 , 52 , 53 , post traumatic stress disorder (PTSD) 54 , and risk of suicide 51 , 52 . Japan has a higher prevalence of school bullying compared to most other countries (i.e., Japan 22% vs OECD countries 19%) 55 . This study showed that the prevalence was low in elderly population. The possible reasons for this low prevalence may less awareness, different school dynamics (societal norms), and supportive community functions in old Japanese 56 . A previous study indicated the widely varied exposure to bullying across countries 57 , even in one country, the prevalence may vary from generation to generation. To reduce the prevalence, evidence-based practice is needed to be implemented at school 58 .

Natural disasters as one of ACEs was overall experienced 3.5% and impacted on severe psychological distress in adulthood, except those 65 or older. The findings were in line with the previous studies, demonstrating that when experiencing natural disaster, such as earthquake, heavy rain/snowfall, flood, heatwaves, storm, and/or tsunami, can cause short-term and long-term deterioration in mental health 59 , 60 , 61 , 62 . The worldwide climate is rapidly changing and we face the increased risk of natural disaster. Assessing the psychological impact that the experience of natural disaster(s) causes may become increasingly important in the near future, in addition to the effort to avoid children from being exposed such traumatic events.

Childhood poverty was experienced more in older age (40% in 65 or older; 17% in 18–34-year-old group), but the negative impact on mental health was less among the elderly population. This result was in line with a previous study showing that accumulative exposure of the economic hardship impacted mental health, but that negative association was attenuated if they experienced upwards mobility 63 . Many of elderly population in this study experienced childhood poverty, but financial difficulty might not persist and change positively. Even so, we should not ignore the importance of childhood poverty for mental health in adulthood, as significant effects have also been found in older adults. A possible mechanism of the link between childhood poverty and mental health are presented; persistent poverty-related challenging tasks 64 , disengagement coping strategy 65 , diminished spatial short-term memory, and helplessness behaviors 66 . Poverty is not only one of the critical social determinants of health 67 , but also an adversity that should primarily be addressed during childhood, when it has significant implications for neurodevelopment, social development, and behavior. The findings of the present study posed the need to ensure that poverty does not persist among the young generation, who suffered economically in childhood.

Overall, this study showed the cumulative negative impacts of expanded ACEs on psychological distress in Japanese adults, as well as individual adversities. A previous study suggested that a 10% reduction in ACE prevalence could equate to annual savings of 3 million DALYs or $105 billion 38 . Primary prevention, or preventing children from having ACEs is urgent action for public mental health. In addition, childhood maltreatment has consistently been shown to be associated with poor treatment outcome after psycho- or pharmaco-therapy in depression 68 . Trauma-informed care can be one of the important approaches to be implemented for tertiary prevention.

Limitations

This study has several limitations. First, generalizability of the findings was limited because this was an online cohort study. Although we adopted sample weighting to adjust the bias and examined the prevalence with large number of participants, we should note that the present result may possibly be different from the real data of community dwelling people in Japan. Participants of online survey have access to the internet and motivation to answer the questionnaire with small reward. It is possible that participants with certain demographic characteristics and traits are likely to participate. Second, a recall bias in terms of measuring ACEs was not avoided. Older participants answered less ACEs may underestimate the impact. Third, the definition of school bullying may also vary between younger and older generations. The authors should note that the outcome of this study was obtained self-report questionnaire and it could cause self-reporting bias. Fourth, there are possibly unconsidered/unmeasured confounding factors. Many factors which can impact on mental health during or after COVID-19 have been presented, but not all factors can be comprehensively considered in the analytic model of this study. Fifth, the number of respondents excluded from the analysis due to inappropriate answer was relatively high. It may be possible that this procedure exclude participants with certain response tendencies. Sixth, although K6 has been shown the relationship with clinical outcome and diagnosis, further study which utilize other clinical assessment may need to be conducted in the future. Seventh, the specific age of having adversity is not clear in this study, although the timing may be important in some ACEs. Future research is needed to consider such detailed information and to examine precise mechanism of the associations of ACEs on health.

Research, policy, and practical implications

Prospective longitudinal study with information about expanded ACEs and clinical diagnosis of mental health disease may be beneficial to suggest the exact impact of ACEs on mental health. Specifically, it is essential to further investigate modifiable childhood factors within the home and school environments to develop effective prevention measures for ACEs through public health policies.

Data availability

The data used in this study are not available in a public repository because they contain personally identifiable or potentially sensitive patient information. Based on the regulations for ethical guidelines in Japan, the Research Ethics Committee of the Osaka International Cancer Institute has imposed restrictions on the dissemination of the data collected in this study. All data enquiries should be addressed to the person responsible for data management, Dr. Takahiro Tabuchi, at the following e-mail address: [email protected].

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Acknowledgements

We thank all study respondents and lab members for their sincere support.

This work was funded by the Japan Society for the Promotion of Science (JSPS) KAKENHI Grants [Grant Number 17H03589;19K10671;19K10446;18H03107; 18H03062;20H00040; 21H04856; 21H03203], the JSPS Grant-in-Aid for Young Scientists [Grant Number 19K19439], Research Support Program to Apply the Wisdom of the University to tackle COVID-19 Related Emergency Problems, University of Tsukuba, and a Health Labour Sciences Research Grant [Grant Number 19FA1005;19FG2001;22FA2001; 22FA1010].

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Department of Psychiatric Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan

Yoshiaki Kanamori

Cancer Control Center, Osaka International Cancer Institute, Osaka, Japan

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Department of Public Health, Tokyo Medical and Dental University, Tokyo, Japan

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Author D.N. was in charge of this study, supervising the process, and providing his expert opinion on the subject. Authors N.S., T.T., and D.N. organized the study design. The questionnaire was created through discussions with collaborators outside of this work. N.S. analyzed the data. N.S. wrote the first draft of the manuscript, and T.T., T.F., Y.K., and K.W. revised the manuscript critically. K.W. and Y.K. supported the data analysis. All authors approved the final version of the manuscript. The sponsors played no role in the design of the study; in collecting the data or managing the study; in data analysis; in the interpretation of the data; in the preparation, review, or approval of the manuscript; or in the decision to submit the manuscript for publication.

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Sasaki, N., Watanabe, K., Kanamori, Y. et al. Effects of expanded adverse childhood experiences including school bullying, childhood poverty, and natural disasters on mental health in adulthood. Sci Rep 14 , 12015 (2024). https://doi.org/10.1038/s41598-024-62634-7

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Online bullying and playground taunts can lead to teen mental health issues. Here's how the experts recommend handling a bully

Matt Purcell was just six years old when a group of older boys stuffed him in a council bin and left him to stew in the juices.

It was the final act following months of daily school bus bullying that the Korean-Australian had been keeping to himself.

"I was an adoptee from South Korea and my parents were nothing like me, and that was targeted by bullies at my school," he said.

When his adopted parents learned about the behaviour they called the school and the boys were punished.

The physical assaults stopped, but the school bus taunts continued.

"What bullying does, it dehumanises you," Mr Purcell said.

"Being bullied at the age of six right through to high school made me feel like not a human. I struggled with my identity for years.

"My life was pretty sad for a long time."

His father enrolled him in Kung Fu classes, but that also caused problems when Mr Purcell responded to the bullies with his own violence.

"If it wasn't for mentors in my life who pursued me, I wouldn't be here today."

This week an international study found Australia's teens experience bullying at the second highest rate among developed countries.

The Australian Council for Educational Research analysed data from the OECD's Program for International Student Assessment (PISA) test which surveyed more than 13,437 Australian students in 2022.

It found Australia ranked number two for bullying, with 17 per cent of students reporting that "other students made fun of me" but the overall trend was down compared to 2018.

Students in Tasmania reported the highest levels of bullying with the lowest in Victoria, NSW and the ACT.

The study found teen girls were reporting anxiety, fear and panic at twice the rate of boys, but boys appeared more resilient to stress than girls.

Bullying can send some teens to the brink

Bullying is a type of trauma that falls under the banner of Adverse Childhood Experiences (ACE) and it may be contributing to the current surge in youth mental health problems.

"These mental health issues that appear in adolescence, they don't just happen overnight. Usually there's been precursors through the early childhood years," Children's Commissioner Anne Hollonds said.

Numerous studies have found bullying, including cyberbullying, is widespread and more than two-thirds of children aged 12 to 13 have experienced at least one bullying-like behaviour in a 12-month period.

Online, approximately one in four Australians aged between 14 and 17 have been the victim of cyberbullying in the past year.

A major 2021 Australian review found that of all the Adverse Childhood Experiences, bullying — including cyberbullying — was associated with double the risk of suicide in later life.

Teens who were victims of cyberbullying were more likely to report elevated symptoms of depression or anxiety, and the use of social media in particular, was also associated with a high risk of depression and anxiety.

The impact of being left out

Dr Deirdre Gartland leads the Resilience and Mental Health research program at Murdoch Children's Research Institute and says long term bullying could impact how children regulate their emotions, causing them to miss school or disengage at home.

"Ongoing stresses that are persistent and significant for a young person are going to affect how the pathways in the brain develop," she said.

Commissioner Hollonds said greater focus was needed on what she called "the middle years" — ages 8 to 14.

"What we now know is that in those years children are really looking for a sense of belonging," she said.

"If they're not able to build that sense of belonging at school, then that will lead to them starting to disengage from school or to behave in ways that causes them actually to be pushed out."

In a bid to address the impacts of bullying, funding of $4.2 million for school resources and programs such as the Anti-Bullying Collective and the National Day of Action against Bullying and Violence, was allocated in last week's federal budget.

What can parents do?

Dr Gartland said there were facets of life that proved to have a protective effect when it came to resilience and coping with traumatic events like bullying.

These include:

• Fostering a positive sense of self-identity
• Maintaining a good connection to family and friends
• Maintaining a strong connection to culture
• Ensuring teens are enjoying hobbies or activities outside of school hours
• Family guidance
• Ensuring there's a positive engagement with the school and the teachers there
• Fostering a sense of optimism for the future; and
• Helping teens build the capacity to identify and regulate their emotions

She said parents could facilitate some of these by having family traditions like birthdays or family holidays or enrol children in language courses to help them connect to their culture as well as extra-curricular activities such as sport, music or art.

"Connecting in with something that your child or young person really enjoys doing is a really wonderful way to build their resilience," she said.

Parents also needed to be role models and help children understand their emotions during turbulent times.

"Parents can be helping children and young people to both name and recognise their feelings," she said.

Commissioner Hollonds said parents should try to find creative ways to stay connected with teens — whether it be watching trashy television together or cooking a meal.

"Don't think that just because they don't seem to want to spend time with you that that means they don't want you around. Teenagers want you around. That's a fact," she said.

"The more time you spend with them and have those incidental conversations, the more you get a sense of what that child's well-being is over time."

Resilience isn't about 'bouncing back'

Dr Gartland said it was important to remember that resilience did not mean "bouncing back".

"Resilience is about a child or a young person drawing on their internal strengths and drawing on the strengths and resources that sit around them," she said.

"When children do have access to these resources, they are much more likely to have positive mental health and well-being irrespective of what's happening to them in their lives."

Mr Purcell urged parents to become detectives in their teens' lives and use "I statements" such as, "I noticed you've not being going to basketball" to try to draw out what was wrong while sitting shoulder to shoulder with their teen.

"So you've got to get the information out — who's doing what and is this a pattern?" he said.

"Make a decision. Do I need to make my kid move school? Do I need to have a conversation?"

He suggested parents relate their own school experiences to help connect with their teen and even use themselves as a soft target to role play ways to deal with bullies.

"It's a verbal dojo. We practice questioning back to each other. How could I come back to that? Is that actually true?" he explained.

And what not to do…

A key message from the experts to parents is to avoid common cliches like "just ignore them" or "well, just hit them back".

Dr Gartland said those kinds of messages could be damaging.

"It's really important to acknowledge the challenges that young people and children may be going through."

Years after his own bullying experience Mr Purcell became a youth worker and noticed other young people also didn't have the skills to combat verbal abuse.

As a result, he created Social Kung Fu, a program designed to give young people the words and phrases to combat schoolyard and online bullying.

Teens are given mock scripts and taught to use questions like, "what do you mean by that?" and "how do you know it's true?" as verbal blocks to put those spreading rumours and making accusations on the back foot.

Mr Purcell said responding with violence escalated the situation instead of resolving it, and while ignoring bullies may work for one-off incidents, he believed it was less effective for ongoing targeting.

"By being passive you're teaching the bully it's okay," he said.

Mr Purcell said the answer lay in teaching young people that their words could have tremendous impact.

"If we can help people use their words to defend themselves and to give value, then I believe that [good] mental health will increase," he said.

Mental health disorders among young people have soared by nearly 50 per cent in 15 years. The ABC is talking to youth, parents, and researchers about what's driving this pattern, and what can be done to turn things around.

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